Prevention Of Mental Disorders And Public Mental Health: A .

Prevention of Mental Disorders and PublicMental Health: A Life CourseDevelopmental EpidemiologicalFrameworkDr. Nick Ialongo and Dr. George RebokDepartment of Mental HealthJohns Hopkins Bloomberg School of Public Health330.673.11Summer Institute in Mental Health Research

Public Health Definition of MentalDisorder Prevention Mental disorder prevention aims at“reducing incidence, prevalence, recurrenceof mental disorders, the time spent withsymptoms, or the risk condition for a mentalillness, preventing or delaying recurrencesand also decreasing the impact of illness inthe affected person, their families and thesociety” (Mrazek & Haggerty, 1994).

Defining Mental Health Promotion “Mental health promotion activities imply thecreation of individual, social, and environmentalconditions that enable optimal psychological andpsychophysiological development. Suchinitiatives involve individuals in the process ofachieving positive mental health, enhancingquality of life and narrowing the gap in healthexpectancy between countries and groups. It is anenabling process, done by, with and for thepeople. Prevention of mental disorders can beconsidered one of the aims and outcomes of abroader mental health promotion strategy(Hosman & Jané-Llopis, 1999).”

A Concept of Prevention That Reflectsthe Integration of Four Perspectives Life course developmentSociologyPublic HealthEpidemiology

Life Course Social Field Framework:Fundamental Tenets and Elements Individuals seen as facing variousdevelopmental tasks and challenges acrossthe major transition points over the life span Tasks and challenges vary within therelevant social fields or contexts in whichdevelopment unfolds

Life Course Social Field Framework:Fundamental Tenets and Elements (cont.) Specific social task demands the individualconfronts through each stage of life aredefined by natural raters. Natural raters not only define the tasks butrate the adequacy of performance of theindividual.

Life Course Social Field Framework:Fundamental Tenets and Elements (cont.) Social adaptation is the response to thesetasks and challenges. Social adaptational status (SAS) is thejudgment of the adequacy of the responseby the natural raters.

Life Course Social Field Framework:Fundamental Tenets and Elements (cont.)Tasks and challenges co-determined by: Normative age-graded (ontogenetic)influences Normative history-graded influences(cohort effects) Non-normative life events

Developmental Influences

Life Course Social Field Framework:Fundamental Tenets and Elements (cont.) Psychological well-being (PWB) refers tothe individual’s internal state. Psychological well-being is in partdetermined by an individual’s perceptionsof his/her successes and failures in meetingthe demands of the natural raters. The relationship between socialadaptational status and psychological wellbeing is a reciprocal one.

Organizational Approach toDevelopment: Basic Principles Competence at one developmental period willexert a positive influence toward achievingcompetence at the next period Early competence also exerts a subtle influencetoward adaptation throughout the life span sinceeach developmental issue is of continuingimportance throughout the life cycle The failure to achieve adaptation at one periodmakes adaptation that much more difficult at thenext and later stages of development Many factors that may mediate between early andlater adaptation or maladaptation may permitalternative outcomes

Normal Development Marked by integration of earlier competencies intolater modes of function With the earlier competencies remainingaccessible, ready to be activated and utilizedduring times of stress, crisis, novelty, andcreativity Thus, early adaptation tends to promote lateradaptation and integration and that greaterflexibility or motility in terms of hierarchicalintegration facilitates this process

Pathological Development Lack of integration of the social, emotional, andcognitive competencies that are important toachieving adaptation at a particular developmentallevel Since early structures often are incorporated intolater structures, early deviation or disturbance infunctioning may ultimately cause much largerdisturbances to emerge later on Pathology may be caused by a lack of motility unterms of hierarchical integration Or else an inability to redifferentiate afterregression in response to stressors

Preventive Intervention Trials Servea Dual Purpose1) Test intervention effectiveness2) Test developmental theory

Theory of Intervention Impact Drives AssessmentFramework: Assess Potential Sources of Variationin Intervention ResponseIncluding factors operating at the level of:- Individual - Family - School - Peer Group - Workplace - Neighborhood/Community and intervention implementation & participation

Assess Potential Sources of Variation inIntervention Response (cont.) Design the next stage of intervention to dealwith those sources of variation

Important to Understand the RelatedConcepts of: Attributable RiskPreventive FractionEquifinalityMultifinality

Attributable Risk The amount or proportion of diseaseincidence (or disease risk) that can beattributed to a specific exposure

Level of Risk and Proportion of Population ReceivingPreventive Interventions, with Illustrative ExamplesUNIVERSAL:Good prenatal and well-baby care to improvecognitive and social emotional developmentSELECTIVE:Programs for people experiencing major stressors,such as job loss, divorce, and natural disasterINDICATED:Cognitive training for children with subclinical depressive symptomsRELAPSE AND COMORBIDITY:Relapse prevention for patients treated for depressionDarker shading indicates increased level of risk

Theoretical %)Student’s At-Risk forProblem Behaviors(5%-15%)Students without SeriousProblem dInterventionsUniversalInterventions(Walker et al., 1996)

A Nested Approach to PreventiveIntervention Programming Acrossthe Life Course

A Nested Approach to PreventiveIntervention Programming Acrossthe Life Course (cont.) Universal, selected, and indicatedinterventions are linked in a seamlessapproach aimed at the reduction of mentaldisorders and substance use.

A Nested Approach to PreventiveIntervention Programming Across the LifeCourse (cont.) Complimentary sets of universalinterventions are implemented at criticalpoints in development (e.g., the transition toelementary, middle, and high school).

A Nested Approach to PreventiveIntervention Programming Across the LifeCourse (cont.) Selective and indicated interventions arethen targeted at those who either fail torespond to the universal interventions,and/or have begun to demonstrate signs ofdisorder.

A Nested Approach to PreventiveIntervention Programming Across the LifeCourse (cont.) Universal interventions aimed at institutionsresponsible for the socialization of copingwith normative developmental challenges(e.g., the transition to school)

A Nested Approach to PreventiveIntervention Programming Across theLife Course (cont.) Universals most likely to help those withmarginal skills in coping with normativechallenges May in turn make these marginallycompetent individuals less vulnerable tonon-normative life events

Universal Can Serve As: A comprehensive screen for those in greaterneed as opposed to cross-sectional point intime assessments Reduce the number of individuals in need ofmore intensive services A docking mechanism for selected,indicated, and treatment interventions

Effectiveness In the usage made standard amongepidemiologists by A.L. Cochrane (19091988), effectiveness is a measure of theextent to which a specific intervention,procedure, regimen, or service, whendeployed in the field in routinecircumstances, does what it is intended todo for a specified population.

Efficacy Extent to which a specific interventionprocedure, regimen, or service provides abeneficial result under ideal conditions.The determination of efficacy is typicallybased on the results of a randomized controltrial.

The Prevention Research CycleFEEDBACKLOOP1. Identifyproblem ordisorder(s)and reviewinformationto determineits extent2. With anemphasis on riskand protectivefactors, reviewrelevantinformation – bothfrom fields outsideprevention andfrom existingpreventiveinterventionresearchprograms3. Design,conduct, andanalyze pilotstudies andconfirmatory andreplication trialsof the preventiveinterventionprogram4. Design,conduct, andanalyze largescale trials ofthe preventiveinterventionprogram5. Facilitatelarge scaleimplementationand ongoingevaluation of thepreventiveinterventionprogram in thecommunity

A Phased Approach for Fielding a CommunityBased Preventive Intervention TrialPhase 11. Meeting with the leaders of the institution wherein theintervention is based and establishing relevance of theproposed work to the needs of the institution and thepopulation it serves.2. Establishing the feasibility of conducting the interventionand its evaluation within the chosen setting3. Determining the acceptability of the proposed interventionto the institution and the targeted individuals in thecommunity4. Establishing the relevance of the outcome assessment tothe institution and the population it serves

A Phased Approach for Fielding a CommunityBased Preventive Intervention TrialPhase 15. The organizational structure(s) within theinstitution responsible for implementing andmaintaining services and programs, which aremost consistent with the nature and goals of theintervention6. Determining the mechanisms and organizationalstructures and resources necessary for theinterventions to continue, if successful, after theresearch is completed

A Phased Approach for Fielding a CommunityBased Preventive Intervention TrialPhase 21. Review data collected from focus groups duringPhase 1, then based on this feedback, refine theintervention and assessment protocols2. Pilot test each intervention with a small number ofparticipants3. Pre- and post-test assessments conducted on thekey outcomes measured4. Assessments of intervention implementationfidelity and the barriers to implementation/participation

A Phased Approach for Fielding a CommunityBased Preventive Intervention TrialPhase 25. Focus groups held with interveners to obtainfeedback on ways to improve interventionprotocols, including training and supervisionprotocols6. Intervention recipients give feedback onrelevance, acceptability, cultural sensitivity, andeffectiveness of intervention components andidentify specific areas of dissatisfaction

A Phased Approach for Fielding a CommunityBased Preventive Intervention TrialPhase 31. Integrate findings from Phases 1 & 2 with the goalof refining the training supervision,implementation, and intervention protocols2. Pilot study of each of the intervention andassessment components carried out with a largernumber of participants3. A control or comparison condition added to detectbetween and within group change4. Focus groups held with participants andinterveners to determine the need for furtherrefinements in the protocols

A Phased Approach for Fielding a CommunityBased Preventive Intervention TrialPhase 35. Cost benefit analysis conducted6. If the effect sizes/benefits relative to the costs arepromising, R01 applications for randomizedcontrol trials submitted

Summary of General Themes Life course developmental perspectiveMultidisciplinary researchParallel preventive interventionsCommunity-based public health approachMultistage developmental evaluationMental health and mental disorder

Life-Course DevelopmentalPerspective Concerned with the description, explanation, andmodification (optimization) of developmentalprocesses in the human life course fromconception to death Life course changes take many forms and vary intheir directionality, time course, degree ofintraindividual and interindividual variability, andmalleability